<form id="add-form" class="form-horizontal" role="form" data-toggle="validator" method="POST" action="">

    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Presentation_id')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-presentation_id" data-rule="required" data-source="presentation/index" class="form-control selectpage form-control" name="row[presentation_id]" type="text" value="">
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Characterisation_of_drug_role')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-characterisation_of_drug_role" class="form-control form-control" name="row[characterisation_of_drug_role]" type="text">
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Mpid_version_date_number')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-mpid_version_date_number" class="form-control form-control" name="row[mpid_version_date_number]" type="text">
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Medicinal_product_identifier_mpid')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-medicinal_product_identifier_mpid" class="form-control form-control" name="row[medicinal_product_identifier_mpid]" type="text">
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Phpid_version_date_number')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-phpid_version_date_number" class="form-control form-control" name="row[phpid_version_date_number]" type="text">
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Pharmaceutical_product_identifier_phpid')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-pharmaceutical_product_identifier_phpid" class="form-control form-control" name="row[pharmaceutical_product_identifier_phpid]" type="text">
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Medicinal_product_name_as_reported_by_the_primary_source')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-medicinal_product_name_as_reported_by_the_primary_source" class="form-control form-control" name="row[medicinal_product_name_as_reported_by_the_primary_source]" type="text">
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Identification_of_the_country_where_the_drug_was_obtained')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-identification_of_the_country_where_the_drug_was_obtained" class="form-control form-control" name="row[identification_of_the_country_where_the_drug_was_obtained]" type="text">
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Investigational_product_blinded')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-investigational_product_blinded" class="form-control form-control" name="row[investigational_product_blinded]" type="text">
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Authorisation_application_number')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-authorisation_application_number" class="form-control form-control" name="row[authorisation_application_number]" type="text">
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Country_of_authorisation_application')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-country_of_authorisation_application" class="form-control form-control" name="row[country_of_authorisation_application]" type="text">
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Name_of_holder_applicant')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-name_of_holder_applicant" class="form-control form-control" name="row[name_of_holder_applicant]" type="text">
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Cumulative_dose_to_first_reaction_number')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-cumulative_dose_to_first_reaction_number" class="form-control form-control" name="row[cumulative_dose_to_first_reaction_number]" type="text">
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Cumulative_dose_to_first_reaction_unit')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-cumulative_dose_to_first_reaction_unit" class="form-control form-control" name="row[cumulative_dose_to_first_reaction_unit]" type="text">
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Gestation_period_at_time_of_exposure_number')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-gestation_period_at_time_of_exposure_number" class="form-control form-control" name="row[gestation_period_at_time_of_exposure_number]" type="text">
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Gestation_period_at_time_of_exposure_unit')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-gestation_period_at_time_of_exposure_unit" class="form-control form-control" name="row[gestation_period_at_time_of_exposure_unit]" type="text">
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Actions_taken_with_drug')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-actions_taken_with_drug" class="form-control form-control" name="row[actions_taken_with_drug]" type="text">
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Additional_information_on_drug_free_text')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-additional_information_on_drug_free_text" class="form-control form-control" name="row[additional_information_on_drug_free_text]" type="text">
        </div>
    </div>
    <div class="form-group layer-footer">
        <label class="control-label col-xs-12 col-sm-2"></label>
        <div class="col-xs-12 col-sm-8">
            <button type="submit" class="btn btn-success btn-embossed disabled">{:__('OK')}</button>
            <button type="reset" class="btn btn-default btn-embossed">{:__('Reset')}</button>
        </div>
    </div>
</form>
